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Intra-abdominal injuries are categorized as penetrating or blunt trauma. Penetrating abdominal injuries (ie, gunshot wounds, stab wounds) are serious and usually require surgery. Penetrating ab-dominal trauma results in a high incidence of injury to hollow or-gans, particularly the small bowel. The liver is the most frequently injured solid organ. In gunshot wounds, the most important factor is the velocity at which the missile enters the body. High-velocity missiles (bullets) create extensive tissue damage. All abdominal gunshot wounds that cross the peritoneum or are as-sociated with peritoneal signs require surgical exploration. Stab wounds may be managed nonoperatively.
Blunt trauma to the abdomen may result from motor vehi-cle crashes, falls, blows, or explosions. Blunt trauma is com-monly associated with extra-abdominal injuries to the chest, head, or extremities. Patients with blunt trauma are a challenge because of injuries that may be hidden and difficult to detect. The incidence of delayed and trauma-related complications is greater than for penetrating injuries. This is especially true of blunt injuries involving the liver, kidneys, spleen, or blood ves-sels, which can lead to massive blood loss into the peritoneal cavity.
In conjunction with the history, the abdomen is inspected for ob-vious signs of injury, including penetrating injuries, bruises, and abrasions. Abdominal assessment continues with auscultation of bowel sounds to provide baseline data from which changes can be noted. Absence of bowel sounds may be an early sign of intra-peritoneal involvement, although stress can also decrease or eliminate bowel sounds. Further abdominal assessment may re-veal progressive abdominal distention, involuntary guarding, ten-derness, pain, muscular rigidity, or rebound tenderness along with changes in bowel sounds, all of which are signs of peritoneal irritation. Hypotension and signs and symptoms of shock may also be noted. Additionally, the chest and other body systems are assessed for injuries that frequently accompany intra-abdominal injuries.
Laboratory studies that aid in assessment include the following:
· Urinalysis to detect hematuria (indicative of a urinary tract injury)
· Serial hematocrit levels to evaluate trends reflecting the presence or absence of bleeding
· White blood cell count to detect elevation (generally asso-ciated with trauma)
· Serum amylase analysis to detect rising levels, which sug-gest pancreatic injury or perforation of the gastrointestinal tract
Hemorrhage frequently accompanies abdominal injury, espe-cially if the liver or spleen has been traumatized. Therefore, the patient is assessed continuously for signs and symptoms of exter-nal and internal bleeding. The front of the body, flanks, and back are inspected for bluish discoloration, asymmetry, abrasion, and contusion. Abdominal CT scans permit detailed evaluation of ab-dominal contents and retroperitoneal examination. Abdominal ultrasound studies can rapidly assess hemodynamically unstable patients to detect intraperitoneal bleeding and pericardial tam-ponade. This is referred to as the FAST (Focused Assessment for Sonographic Examination of the Trauma Patient) examination. Pain in the left shoulder is common in a patient with bleeding from a ruptured spleen, whereas pain in the right shoulder can re-sult from laceration of the liver. Even though the patient com-plains of pain, administration of opioids is avoided during the observation period because their effect may obscure the clinical picture.
The abdomen is assessed for tenderness, rebound tenderness, guarding, rigidity, spasm, increasing distention, and pain. Referred pain is a significant finding because it suggests intraperitoneal in-jury. To determine whether there is intraperitoneal injury and bleeding, the patient is usually prepared for diagnostic procedures, such as peritoneal lavage, abdominal ultrasonography, or abdom-inal computed tomography (CT) scanning. Diagnostic peritoneallavage involves the instillation of 1 L of warmed lactated Ringer’sor normal saline solution into the abdominal cavity. After a min-imum of 400 mL has been returned, a fluid specimen is sent to the laboratory for analysis. Positive laboratory findings include a red blood cell count higher than 100,000/mm3, a white blood cell count exceeding 500/mm3, or the presence of bile, feces, or food.In patients with stab wounds, sinography may be performed to detect peritoneal penetration. With this procedure, a purse-string suture is placed around the wound, and a small catheter is introduced through the wound. A contrast agent is then intro-duced through the catheter, and x-rays are taken to identify any peritoneal penetration.
A rectal or vaginal examination is performed to determine any injury to the pelvis, bladder, and intestinal wall. To decompress the bladder and monitor urine output, an indwelling catheter is inserted after a rectal examination (not before). In the male pa-tient, a high-riding prostate gland (abnormal position) discov-ered during a rectal examination indicates a potential urethral injury.
As indicated by the patient’s condition, resuscitation procedures (restoration of airway, breathing, and circulation) are initiated. A patent airway is maintained, and attempts to stabilize the respi-ratory, circulatory, and nervous systems are made. Bleeding is controlled by application of direct pressure to any external bleed-ing wounds and by occlusion of any chest wounds. Circulating blood volume is maintained with intravenous fluid replacement, including blood component therapy. The patient is monitored for signs and symptoms of shock after an initial response to trans-fusion therapy, because these are often the first signs of internal hemorrhage.
With blunt trauma, the patient is kept on a stretcher to im-mobilize the spine. A backboard may be used for transporting the patient to the x-ray department, to the operating room, or to the intensive care unit. Cervical spine immobilization is maintained until cervical x-rays have been obtained and cervical spine injury ruled out.
Knowing the mechanism of injury (eg, penetrating force from a gunshot or knife, blunt force from a blow), is essential to de-termining the type of management needed. All wounds are lo-cated, counted, and documented. If abdominal viscera protrude, the area is covered with sterile, moist saline dressings to keep the viscera from drying.
Typically, oral fluids are withheld in anticipation of surgery, and the stomach contents are aspirated with a nasogastric tube to reduce the risk of aspiration. Nasogastric aspiration also decom-presses the stomach in preparation for diagnostic procedures.
Trauma predisposes the patient to infection by disruption of mechanical barriers, exposure to exogenous bacteria from the en-vironment at the time of injury, and diagnostic and therapeutic procedures (nosocomial infection). Tetanus prophylaxis and broad-spectrum antibiotics are administered as prescribed.
Throughout the stay in the ED, the patient’s condition is con-tinuously monitored for changes. If there is continuing evidence of shock, blood loss, free air under the diaphragm, evisceration, hematuria, or suspected or known abdominal injury, the patient is rapidly transported to surgery. In most cases, blunt liver and spleen injuries are managed nonoperatively.
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